R382-10-18. Enrollment Period and Benefit Changes

  (1) Subject to the provisions in Subsection R382-10-18(2), a child determined eligible for CHIP receives 12 months of coverage that begins with the effective month of enrollment.

  (2) CHIP coverage may end or change before the end of the 12-month certification period if the child:

  (a) turns 19 years of age;

  (b) moves out of the state;

  (c) becomes eligible for Medicaid;

  (d) leaves the household;

  (e) is not eligible, or is eligible for a different plan due to a change described in Subsection R382-10-4(6)(b);

  (f) begins to be covered under a group health plan or other health insurance coverage;

  (g) gains access to state-employee health benefits as defined in 42 CFR 457.310;

  (h) enters a public institution or an institution for mental disease;

  (i) fails to respond to a request to verify access to employer-sponsored health coverage;

  (j) fails to respond to a request to verify reportable changes as described in Subsection R382-10-4(6)(b); or

  (k) does not pay the quarterly premium.

  (3) The agency evaluates changes and may re-determine eligibility when it receives a change report as described in Subsection R382-10-4(6). If the agency requests verification of the change, the agency shall give the client at least 10 days to provide verification. The agency shall provide proper notice of an adverse action.

  (4) If a client reports a change that occurs during the certification period and requests a redetermination, the agency shall re-determine eligibility.

  (a) If an enrollee gains access to health insurance under an employer-sponsored plan or COBRA coverage, the enrollee may switch to UPP. The enrollee must report the health insurance within 10 calendar days of enrolling, or within 10 calendar days of when coverage begins, whichever is later. The employer-sponsored plan must meet UPP criteria.

  (b) If the change would cause an adverse action, eligibility shall remain unchanged through the end of the certification period.

  (c) If the change results in a better benefit, the agency shall take the following actions:

  (i) If the change makes the enrollee eligible for Medicaid, the eligibility agency shall end CHIP eligibility and enroll the child in Medicaid.

  (ii) If the change results in a lower premium, the decrease is effective as follows:

  (A) The premium change is effective the month of report if income decreased that month and the family provides timely verification of income;

  (B) The premium change is effective the month following the report month if the decrease in income is for the following month and the family provides timely verification of income;

  (C) The premium change is effective the month in which verification of the decrease in income is provided, if the family does not provide timely verification of income.

  (5) Failure to make a timely report of a reportable change may result in an overpayment of benefits and case closure.